Rosen & Barkin's 5-Minute Emergency Medicine Consult (527 page)

• ICU:
  
  • Hemodynamic instability
    
  • Cardiac tamponade
    
  • Malignant dysrhythmia
    
  • Status postpericardiocentesis
    
• Telemetry unit:
  
  • Suspicion of myocardial infarction
    
  • Severe pain
    
  • Suspicion of bacterial etiology
    
  • Any high-risk criteria
    
• High-risk criteria:
  
  • Large effusion (>2 cm total)
    
  • Anticoagulant use
    
  • Malignancy
    
  • Temperature >38°C
    
  • Traumatic pericarditis
    
  • Immunosuppression
    
  • Pulsus paradoxus
    
  • Slow onset
    

• Mild symptoms in patients without any hemodynamic compromise
  
• Close follow-up
  
• Able to tolerate a regimen of oral medication
  
• Debate on need for ECG to evaluate for effusion prior to discharge
  

Follow-up with cardiology:

• Recurrent cases
  
• Admitted patients
  

Follow up with primary care physician for re-evaluation and verification of resolution of symptoms and absence of complications in 1–2 wk.

• Classic history: Viral illness preceding development of sharp, positional chest pain
  
• Rub is very specific but not always audible.
  
• The challenge is distinguishing pericarditis from acute MI and other etiologies of chest pain.
  
• Mainstay of therapy is NSAIDs.
  

• Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis.
  Heart Fail Rev.
  2013;18(3):355–360.
  
• Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology.
  Eur Heart J
  . 2004;25:587–610.
  
• Sheth S, Wang DD, Kasapis C. Current and emerging strategies for the treatment of acute pericarditis: A systematic review.
  J Inflamm Res.
  2010;3:135–142
  
• Spodick DH. Acute pericarditis: Current concepts and practice.
  JAMA
  . 2003;289:1150–1153.
  
• Spodick DH. Risk prediction in pericarditis: Who to keep in hospital?
  Heart
  . 2008;94:398–399.
  

See Also (Topic, Algorithm, Electronic Media Element)

Pericardial Effusion/Tamponade

CODES

• 420.90 Acute pericarditis, unspecified
  
• 420.91 Acute idiopathic pericarditis
  
• 423.2 Constrictive pericarditis
  

BASICS

• Lunate remains located and in line with the radius but the distal carpal bones are displaced dorsally (∼95% of the time) or volarly (∼5% of the time)
  
• Early surgical treatment is recommended.
  
• This injury has a high incidence of post-traumatic arthritis.
  

• Mechanism of injury is usually wrist hyperextension with ulnar deviation.
  
• These are high-energy injuries:
  
  • Falls from a height
    
  • Motor vehicle accidents
    
  • Industrial accidents
    
  • Sporting accidents
    

DIAGNOSIS

• Severe wrist pain
  
• Wrist swelling
  
• Diffuse wrist tenderness
  
• Paresthesias in the median nerve distribution
  

• History of a high-energy injury
  
• Any concomitant injuries
  
• Pain in the wrist
  
• May complain of paresthesias in the median nerve distribution
  

• Wrist swelling
  
• Possible deformity of the wrist
  
• Decreased range of motion of the wrist
  
• Possible decreased sensation in the median nerve distribution
  
• Special attention should be paid to skin integrity because open fractures are common.
  
• Neurovascular status should be monitored closely, including 2-point discrimination.
  
• Check closely for concomitant injuries, specifically of the upper extremity.
  

Radiographs of the wrist

• Radiographic imaging that includes 3 views of the wrist
  
• Perilunate dislocation visualized best on the true lateral view:
  
  • Distal carpal row, specifically the capitate, seen dorsally (95% of the time) or volarly (5% of the time) in relation to the lunate
    
  • Lunate is located and in line with the radius
    
• CT and MRI are not generally needed for diagnosis, but some orthopedists may request them for preoperative planning.
  

• Wrists are rarely sprained in children.
  
• Wrist radiographs are difficult to interpret in pediatric patients.
  
• Comparison view of the other wrist may be helpful.
  

• Lunate fracture
  
• Lunate dislocation:
  
  • Dislocation occurs between lunate and distal radius.
    
• Scapholunate dissociation and other similar ligamentous disruptions
  
• Distal radius fracture
  

Consider nonaccidental trauma.

TREATMENT

• Assess for other injuries
  
• Immobilize
  
• Pain control
  
• Elevate
  

• Identify other, more serious, associated injuries.
  
• Immobilize
  
• Elevate
  
• Ice
  

• Pain control
  
• Procedural sedation for closed reduction:
  
  • Etomidate: 0.1–0.15 mg/kg IV
    
  • Methohexital: 1–1.5 mg/kg IV
    
  • Propofol: 40 mg IV every 10 sec until induction
    
• Closed reduction of the dislocation should be done emergently:
  
  • Arm is hung in traction for 10 min with 10–15 lb of counterweights and the fingers in traps.
    
  • The fingers are then removed from the traps and manual traction is continued.
    
  • One of the physician’s thumbs is placed volarly over the lunate and then the injury is recreated with wrist extension.
    
  • Continued traction is applied to the wrist and then slow flexion of the wrist is performed, which usually locates the distal carpal bones.
    
• Operative fixation to reduce and maintain wrist stability is required.
  
• Immobilize wrist using a sugar-tong splint in neutral position. Obtain postreduction radiograph.
  

Although perilunate dislocation is unusual in pediatric patients, children with wrist pain should be splinted and referred to a pediatric hand surgeon.

• Diazepam: 2–5 mg IV q2–4h (peds: Max. dose is 0.25 mg/kg q4h) PRN anxiety
  
• Fentanyl: 0.05–0.2 mg IV q1h PRN pain
  
• Hydromorphone: 0.5–1 mg IV q4–6h (peds: 0.015 mg/kg/dose q4–6h) PRN pain
  
• Lorazepam: 0.5–1 mg IV q1–6h (peds: 0.044 mg/kg q4–6h) PRN anxiety
  
• Morphine sulfate: 0.1 mg/kg IV q1h PRN pain
  

FOLLOW-UP